Claim Form

Date:.

Branch claim to be submitted.

Ex Vessel “ ; Discharged on the Day of
And delivered into my/our custody on the Day of
Number of Packages/Units to be examined:-
Damaged Packages, which have been separated from the sound, can be seen at (state exact
Locality) Where they are awaiting your inspection.

(*) Notice of damage/loss was given to the Agents of the Vessel “ ;
On the

(*) Notice of damage/loss addressed to the Agents or Owners of the Vessel “ ;
Is attached to this application and I/we request you to forward this on my/or behalf to the
proper party, whose reply will be forwarded to you in due course for notation on the
Certificate of Survey.

Signature(Full Name) of Applicant :-
Address :-
Telephone :-

IMPORTANT

LIABILITY OF CARIERS, BAILEES OR OTHER THIRD PARTIES

It is the duty of the Assured and their agents, in all cases, to take such measures as may be reasonable for the purpose of averting or minimizing a loss and to ensure that all rights against Carriers, Bailees or other third parties are properly preserved and exercised. In particular, the Assured or their Agents are required:-
	1. To claim immediately on the Carriers, Port Authorities or other Bailees for any missing packages.
	2. To apply immediately for survey by Carriers or other Bailees Representatives if any loss or damage be apparent and claim on the Carriers or other Bailees for any actual loss or damage found at such survey.
	3. In no circumstance, except under written protest, to give clean receipts where goods are in doubtful condition.
	4. To give notice in writing to the Carriers or other Bailees within 3 days of delivery if the loss or damage was not apparent at the time of taking delivery.

NOTE:- The Consignees or their Agents are recommended to make themselves familiar with
the Regulations of the Port Authorities at the port of discharge.

DOCUMENTATION OF CLAIMS

To enable claims to be dealt with promptly, the Assured or their Agents are advised to submit all available supporting documents without delay, including when applicable:-
	1. Original policy or certificate of Insurance.
	2. Original or copy shipping invoices, together with shipping specification and/or weight notes.
	3. Original Bill of Lading and/or other contract of carriage.
	4. Survey report or other documentary evidence to show the extent of the loss or damage.
	5. Landing account and weight notes at a final destination.
	6. Correspondence exchanged with the Carriers and other parties regarding their liability for the loss or damage.

	Date:

To the Owners or Agents at Of the Vessel “



	Goods :

Marks and Numbers:

* Here Insert If possible particulars of the quantity of goods damaged or lost. If the quantity if not definitely known say “a part; or a quantity or some such general term		I/We have to inform you that of the above goods deliverable to me/us ex the On (date) are found to be damaged/lost and I/we beg to notify you that I/we hold Owners of the vessel as Carriers responsible for this damage/loss.

		The goods delivered are at present lying at Where they will be surveyed by Ethiopian Insurance Corp. or their Agents on th e And you are Invited to attend the survey. Please acknowledge receipt of this notice on the form attached

Signed (Full Name):
Date:

Messrs.
Goods:		ex:

	I/We have to acknowledge receipt of your Notice of damage/loss in respect of the above shipment and to inform you that

Singed (Full Name):